By Adriane Fugh-Berman and Charlea Massion
Back when we were in training, more than 30 years ago, opioids were considered dangerous drugs that could cause addiction and life-threatening respiratory depression. Medical students were taught that opioids were very useful for end-of-life pain (especially for cancer, which can cause excruciating pain) and that they were important for a few days after surgery or a severe injury. From the 1990s until today, however, pharmaceutical companies have stealthily distorted perceptions about opioids on the part of both consumers and health care providers. These manufacturers should be held responsible for today’s opioid addiction epidemic.[a]
Grim, new statistics are announced almost daily that describe the tragic scope of the U.S. opioid epidemic. Drug overdoses, primarily from opioids, are now the leading cause of death for Americans under age 50. In 2016, drug overdoses killed more people that guns or car accidents, outnumbering deaths at the peak of the HIV epidemic.
How did Pharma engineer this? Opioid manufacturers paid physicians who were identified as “key opinion leaders” to persuade their peers to prescribe more opioids; misused articles in medical journals to tout opioids’ benefits; and created continuing medical education to misinform physicians about opioids’ risks. At the same time, pharmaceutical companies convinced health care providers that they were torturing patients by undertreating pain, and that patients don’t’ get addicted to pain medication.
Neither is true. The expansion of the use of opioids beyond end-of-life care into treating back pain, arthritis, irritable bowel syndrome, and other painful chronic conditions was a bad mistake. It has ended up addicting many patients who were simply following their health care providers’ directions. Yet, despite record-level deaths from these drugs, many doctors continue to accept payments for promoting opioids. A recent study found that, between 2013 and 2015, the pharmaceutical industry paid U.S. doctors more than $46 million for opioid-promoting activities. Most of these payments, 63%, were given to physicians as speaking fees or honoraria. About 1 in 12 U.S. physicians received an industry payment involving an opioid over this timeframe.
Americans comprise less than 5% of the world’s population but use 80% of all opioids consumed worldwide (including 99% of hydrocodone). We use more opioids as we age; in 2011, 1 in every 11 adults over age 65 was taking opioid pain medications. The use of opioids for pain treatment has increased among elders at the same time as the use of non-steroidal anti-inflammatory drugs (NSAIDs) has decreased.2 Although it is dangerous to combine opioids with benzodiazepines (i.e., Valium, Xanax, Ativan, and related drugs), or muscle relaxants, surveys show that nearly 60% of opioid medication users are taking a risky combination of these prescription drugs.
Much is made of the fact that 20% Americans report using prescription opioids for nonmedical use, and that 80% of heroin users reported that their opioid use began with opioid pain relievers.3Those are startling statistics—but it’s a misperception to think that most opioid deaths are caused by opioid misuse or abuse. In fact, many deaths occur when people are using their drugs in exactly the way they were prescribed. Abuse isn’t the problem; use is the problem.
One study found that more than half of 1.14 million people hospitalized for reasons other than surgery were given opioids. Part of the reason for this is that the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which is used to determine hospital payments, contains four questions about whether a patient received adequate pain relief while hospitalized. Hospitals have been so concerned about their HCAHPS scores that they pressured physicians to prescribe opioids. The good news is that pressure from the great nonprofit group Physicians for Responsible Opioid Prescribing has convinced the Centers for Medicare and Medicaid Services (CMS) to stop using the pain questions in hospital ratings. This will hopefully remove this financial incentive to prescribe more opioids.
Opioids’ adverse effects include a higher risk of death, cardiovascular problems, addiction, memory problems, sleep problems, vomiting, severe constipation, sweating, weight gain, sexual dysfunction, dry mouth, itching, dizziness, and urinary retention. For most people, long-term opioid use is a bad idea, and not just because of these adverse effects.
Opioids often lose effectiveness over time; ironically, they can cause increased sensitivity to pain (called hyperalgesia). Wiithdrawal symptoms can include pain, so someone trying to get off of opioids may think they need to keep taking them due to pain caused by trying to stop taking opioids. And, while people may need higher and higher doses over time to treat pain, higher doses cause more adverse effects. Unfortunately, tolerance to painkilling effects does not correlate with tolerance of adverse effects; in other words, one could still be in pain and die from too much opioids.
Anyone can become addicted, and even a week of opioids can lead patients into addiction. The best way to avoid the adverse effects of opioids include is to avoid using them in the first place. Up to three days of opioid use after having surgery or experiencing an acute injury is warranted; liberal use of opioids is also appropriate for end-of-life care. If you’re in the hospital for other reasons, refuse opioids; if opioids are necessary, limit their use to three days or less.
For chronic pain, avoid all opioids and try other options, such as: NSAIDs (i.e., ibuprofen, aspirin, and naproxyn); topical pain relievers containing capsaicin, ketoprofen, or diclofenac; or nerve blocks. Explore other options before even considering opioids for chronic pain, including exercise, physical therapy, massage, osteopathic or chiropractic adjustment, acupuncture, yoga, cognitive behavioral therapy, and manipulative techniques.
[a] Prescription opioids include oxycodone, hydrocodone, fentanyl, morphine, tapentadol, codeine, buprenorphine, and tramadol. Some health care providers don’t know that tramadol, is an opioid, but it is.
 Katz J, “Short Answers to Hard Questions About the Opioid Crisis,” The New York Times, August 3, 2017. Online:https://www.nytimes.com/interactive/2017/08/03/upshot/opioid-drug-overdose-epidemic.html?_r=0
 Hadland SE, Krieger MS, Marshall BDL, “Industry Payments to Physicians for Opioid Products, 2013–2015,” American Journal of Public Health 2017; 107(9): 1493-1495. DOI: 10.2105/AJPH.2017.303982
 Manchikanti L, Kaye AM, Kaye AD, “Current State of Opioid Therapy and Abuse,” Curr Pain Headache Rep 2016; 20(5): 34.
 Kaye AD, Jones MR, Kaye AM, et al., “Prescription Opioid Abuse in Chronic Pain: An Updated Review of Opioid Abuse Predictors and Strategies to Curb Opioid Abuse: Part 1,” Pain Physician2017; 20(2S): S93-S109.
 Herzig SJ, Rothberg MB, Cheung M, et al., “Opioid Utilization and Opioid Related Adverse Events in Nonsurgical Patients in US Hospitals,” J. Hosp. Med. 2014; 9: 73–81.